Perioperative cefazolin prescribing rates following suppression of alerts for non-IgE-mediated penicillin allergies.

BACKGROUND: Cefazolin is the preferred antimicrobial for the prevention of surgical site infections (SSIs) in many procedures. The presence of penicillin allergies can influence prescribing of alternative agents like vancomycin. In April 2022, Nebraska Medicine implemented a suppression of alerts for non-IgE-mediated and nonsevere penicillin allergies in the electronic medical record (EMR) upon cephalosporin prescribing. The objective of this study was to evaluate changes in perioperative cefazolin for SSI prophylaxis. METHODS: This was a quasi-experimental study of patients undergoing procedures for which cefazolin was the preferred agent per institutional guidance. Education on the change was distributed via e-mail to surgical staff and pharmacists. Pre- and post-intervention data were collected from April 2021 through March 2022 and April 11, 2022, through October 2022, respectively. Chart review was performed on patients with reported penicillin allergies for the top surgical procedures with <50% cefazolin utilization pre-intervention. The primary outcome was the administration of perioperative cefazolin in patients with penicillin allergies, including unknown reactions. RESULTS: A total of 6,676 patients underwent surgical procedures (pre-intervention n = 4,147, post-intervention n = 2,529). Documented penicillin allergies were similar between the pre- and post-intervention group (12.3% vs. 12.6%). In individuals with documented penicillin allergies, cefazolin prescribing increased from 49.6% to 74.3% (p < 0.01). Chart review for safety outcomes identified no difference in new severe reactions, rescue medication, SSIs, acute kidney injury, postoperative Clostridioides difficile infection, or methicillin-resistant Staphylococcus aureus infections. CONCLUSION: Following the suppression of EMR alerts for non-IgE-mediated and nonsevere penicillin allergies, cefazolin prescribing rates for SSI prophylaxis significantly improved.

Use of a Novel Clinical Decision Support Tool for Pharmacist-Led Antimicrobial Stewardship in Patients with Normal Procalcitonin.

In 2018, a clinical decision support (CDS) tool was implemented as part of a "daily checklist" for frontline pharmacists to review patients on antibiotics with procalcitonin (PCT) <0.25 mcg/L. This study used a retrospective cohort design to assess change in antibiotic use from pharmacist interventions after this PCT alert in patients on antibiotics for lower respiratory tract infections (LRTI). The secondary outcome was antibiotic days of therapy (DOT), with a subgroup analysis examining antibiotic use and the length of stay (LOS) in patients with a pharmacist intervention. From 1/2019 to 11/2019, there were 165 alerts in 116 unique patients on antibiotics for LRTI. Pharmacists attempted interventions after 34 (20.6%) of these alerts, with narrowing spectrum or converting to oral being the most common interventions. Pharmacist interventions prevented 125 DOT in the hospital. Vancomycin was the most commonly discontinued antibiotic with an 85.3% use reduction in patients with interventions compared to a 27.4% discontinuation in patients without documented intervention (p = 0.0156). The LOS was similar in both groups (median 6.4 days vs. 7 days, p = 0.81). In conclusion, interventions driven by a CDS tool for pharmacist-driven antimicrobial stewardship in patients with a normal PCT resulted in fewer DOT and significantly higher rates of vancomycin discontinuation.

Is it time to call it quits on low-dose quetiapine?

The mandate of the Centers for Medicare & Medicaid Services to decrease the use of antipsychotics in long-term care facilities requires creative solutions. Low-dose quetiapine is used for a multitude of behavioral disorders and sleep problems in the nursing facility population. Yet, at doses of 25 mg per day or less, it doesn't have strong affinity (if any) for the dopamine-2 (D2) receptor, but it does maintain affinity for the histamine-1 and alpha-1 receptors. This begs the question: If it's not antagonizing the D2 receptor, could the use of something with similar receptor-affinity produce the same result, allowing discontinuation of the antipsychotic altogether? Using knowledge of receptor affinities and the pharmacologic action of low-dose quetiapine, consultant pharmacists may have one additional tool in their armamentarium of fighting inappropriate antipsychotic use.